Let Me Make One Thing Perfectly 'Clear'

Toward a better pre-op visit

Earlier this week, one of the residents and I saw a new patient who apparently had been sent in to see us for a pre-op visit, an evaluation to make sure that her medical conditions were well controlled and that the surgery was safe for the surgeons to proceed with. She reported that she forgot the paperwork they gave her. All she knew was that whatever we wrote had to clearly state "medically cleared for surgery."

Unfortunately, she also did not know much (if anything) about her own medical history, nor did she know when the surgery was, by whom, or even on what body part.

Makes it kind of hard to "clear" someone or do an effective preoperative evaluation.

(And I cannot tell you how much I hate that word "clear." All we can do is guide, we cannot predict the future.)

The pre-op visit has long been one of the bread-and-butter types of visits for internal medicine physicians, and many in practice love seeing them. A patient they know well getting cleared for a minor procedure allows them to quickly get through a visit and bill for a consultation with only a modicum of extra effort.

We all have our standard questions that we ask for preoperative evaluation, exercise tolerance, easy bleeding or bruising, an accurate medication list, allergies, prior complications from surgery or anesthesia, and so on.

Then a quick in-office EKG or chest x-ray if requested by the surgeon or mandated by their medical conditions, some labs, a quick consult note, and you're done.

But as often happens with our patient, either we don't know enough about them to figure out whether the surgery is safe, or they don't know enough about the surgery for us to tell them whether the surgery is safe.

Having a surgeon ask you the right questions is better than filling out all the forms in the world.

Tells us what the surgery entails, and why you think this might impart risk to the patient. What anesthesia is planned (most often left off information on their requests)? What are you as the surgeon worried about?

We also get pre-op clearance visits that seem sublime bordering on the ridiculous.

A healthy person without any medical conditions sent in for a pre-op medical clearance prior to bunion surgery. Or a colonoscopy. Or a biopsy. Or an injection. Or a dental cleaning.

As long as we're redesigning the healthcare system, perhaps we can figure better ways to streamline this process, make it more efficient and more effective, more patient-centered.

For years, ophthalmology has been sending us patients by the dozens every month for medical clearance prior to cataract surgery.

When I started out working here, such a long time ago, the preoperative evaluation included a CBC, metabolic profile, PT, PTT, EKG, and even a chest x-ray.

Over the years, as the literature on the utility (or lack thereof) of preoperative lab and other testing in the setting of various types of surgery has grown, our colleagues in ophthalmology have grown more sophisticated in their requests, paring down the need for these extraneous evaluations.

Indeed, most studies have shown that even when abnormalities were detected on preoperative testing, very little was done to act on them, and most had very little or no effect on the patient's risk of outcome from the procedures undertaken.

A few years ago, we started getting notes from referring doctors that said something along the lines of "preoperative testing as felt appropriate by the medical consultant," leaving it up to us to decide what the patient might need done.

Contrast this to the old days, where patients wouldn't even be allowed into the procedure suite without that EKG, chest x-ray, labs, and a signed note of medical clearance.

Let me tell you about two my favorite medical clearance cases.

One involved an elderly gentleman we cared for with advanced heart failure, his ejection fraction so low that if he skipped a dose of his medications he pretty quickly went into florid heart failure and often ended up in the CCU. He was unable to lie flat since his condition had developed, and he long ago had resorted to sleeping sitting upright in a recliner chair at home.

When we arranged for his medical clearance for his cataract surgery we included, in large letters, highlighted on the form, circled and underlined, that he could not be placed below an angle of 45°, since this would likely result in very bad things happening, such as intubation and intravenous diuretics.

I'll never forget the day of his procedure, when they called me from the operative suite, demanding to know why we had cleared him for surgery and why he would not let them push him down flat on the table. He later recounted to me that they had two OR techs pushing on him, trying to get him to lie flat, and all he kept screaming was "Call Dr. Pelzman!" Later we discovered that no one actually looked at the pre-op paperwork that we faxed to their office, which they had demanded be received before they would even set up a surgery date.

Contrast this with another preoperative evaluation I did for an elderly patient of mine who required semi-urgent surgery, and I evaluated him in the emergency room with the surgeon. We all talked about how the surgery was absolutely necessary, and that he was at high risk, and the surgeon looked at me and said "How about pre-op beta blocker," to which I replied, "Sounds right to me," and that was it.

Off to the OR he went.

Our colleagues here in ophthalmology have been at the forefront of trying to simplify this process and, working with internists, have developed a new set of criteria that allow them to decide who needs a pre-op clearance, who just needs an A-OK from the doctor and who needs a more formal appointment for more intensive evaluation.

Using the functionality of our electronic medical record, where we can all see what a patient's medical problems are, a template of standardized questions will allow the staff at ophthalmology to decide who needs what, thereby preventing a lot of excess healthcare resource utilization and inconvenience for patients.

As we continue to build this process out and expand it beyond cataract surgery, we should start to use the electronic health record as a shared knowledge base, a place where we can communicate about the patient and make medical decisions based on the best evidence and what makes the most sense to get our patients the care they need in a timely fashion.

Gone should be the days where a surgeon sends us a form to fill out that has information that they can completely collect on their own, or that is visible within the same electronic health record.

Ask us the right questions and we will be happy to offer guidance.

For the most part, these could be handled in a smooth, seamless, and professional way by doctors working together to take the best care of our patients.

Never again should we have to handwrite a patient's medication list from our electronic health record onto a paper form that someone's going fax and then scan back into the same electronic medical record, and then never look at again.

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